So a few months ago I posted about central line insertion and my concerns about the current standardization of care of ultrasound guidance:
I promised a video so finally got around to remembering to do it. This one actually happens to be a dialysis catheter so a bit bigger, but otherwise the technique is the same. In this case I am using my standard ultrasound-spotted procedure with “blind” insertion.
So here, I spot the vein, confirm it is just lateral to the carotid, and that it collapses nicely, without thrombosis:
Now, I insert the line. A few important points to note that are not seen in the frame:
Line Insertion video:
a. my introducer needle/syringe and loaded guide wire (pulled pack and “loaded”) are ready and within my vision, and also nearby are the dilator and catheter.
b. note that the off hand (right hand in this line) protects the carotid and stays in place until there is venous flashback, then secures the needle position.
Note that in this particular case, I didn’t quite make a large enough incision so the dilator insertion was a little difficult – unnecessary delay, and also unfortunately lost the last few seconds as my iPhone memory was full.
Next, I confirm position in the internal jugular vein, and verify for lung sliding to rule out and anterior/apical pneumothorax.
In me experience, the key mistake I see inexperienced operators (and sadly, some experienced ones also) make is not to have a proper setup, such that once they do find the vein with the introducer needle, their subsequent steps are not immediately ready, and in the process, the relationship between needle tip and vein is lost, resulting in an inability to thread the guidewire (often blamed on mysterious anatomical abnormalities). It is key to find the vein with the freezing/searcher needle, fix the depth/angle relationship in your mind, withdraw and reach for the introducer needle/syringe using peripheral vision so as not to break the visual fix, and reproduce this while introducing it.
This is what I try to install in students/residents rounding with me, and in fact this approach is useful for any procedure. Not having to turn your head, reach and fiddle with things that are not ready prevents mistakes.
If you haven’t read my previous post on central line insertion, I’m not advocating agains the use of ultrasound guidance, but for the maintenance of the ability to insert blind lines if necessary.